The WasteWatcher: The Staff Blog of Citizens Against Government Waste

The Summer of Healthcare Discontent

The WasteWatcher is the staff blog of Citizens Against Government Waste (CAGW) and the Council for Citizens Against Government Waste (CCAGW). For questions, contact blog@cagw.org.


As the end of their summer recess approaches, the Republican-controlled Congress has still not done what it has promised to do since March 2010:  repeal the Patient Protection and Affordable Care Act (ACA), or Obamacare, and allow consumer-driven forces to create more competition and choices in order to drive down healthcare costs.  It has been said that Republicans behaved like a dog which had constantly chased after a car and then finally caught it:  They were ill-prepared about what to do after Obamacare was snagged in their metaphorical jaws.

After 12 weeks of wrangling over a healthcare bill to repeal and replace Obamacare, House Republicans produced legislation, H.R. 1628, the American Health Care Act (AHCA), which passed by a vote of 217 to 213; 20 Republicans and every Democrat voted no.  But 18 of the 20 Republicans who voted “nay” on AHCA, which had a chance of being signed into law under President Trump, had voted “yea” two years earlier for a far more conservative repeal-only bill that had no chance of being signed into law by President Obama.  That bill, H.R. 3762, the Restoring American’s Healthcare Freedom Reconciliation Act, easily passed the House in October 2015 by a vote of 240 to 189, with 239 Republican and one Democratic “yea” votes and 182 Democratic and seven Republican “nay” votes.

While not a perfect bill, the AHCA would have implemented significant policy changes that Republicans had supported for years.  The legislation repealed the individual and employer mandates by zeroing out the tax for not purchasing health insurance; expanded the use of tax-free health savings accounts (HSAs); created advanceable, refundable tax credits, based on age, for individuals with annual incomes up to $75,000 that would have helped people pay for health insurance; provided $138 billion in grants to the states and a federal risk-sharing program to stabilize the individual health insurance market; and, made significant reforms to Medicaid such as putting the program on a budget for the first time, while allowing states to have more control in running it.

Soon after AHCA’s passage, Senate Majority Leader Mitch McConnell (R-Ky.) declared that the Senate would write its own bill and created a 13-member working group to put it together.  On June 22, 2017, a discussion draft, the Better Care Reconciliation Act (BCRA), was produced.

The BCRA made changes to the House bill, such as allowing those with yearly incomes between zero to 350 percent of the federal poverty level ($42,210), instead of up to $75,000, to receive a premium tax credit, and provided greater funding for states to stabilize marketplaces.  Opposition to the legislation was almost immediate from several of McConnell’s fellow Republicans, many of them wrangling publicly that the legislation either did not go far enough, or went too far to repeal Obamacare, and that the entire bill-writing process was being conducted behind closed doors.

With no hope of getting any support from Democrats, it became clear there would not be enough votes to pass anything before the Independence Day holiday.  Leader McConnell declared more time was needed to rally his troops to get to “yea.”

Immediately after returning from their July 4 holiday break, senators were told their August recess would be delayed until something passed.  First, the Senate needed to approve a motion to proceed to debate the House bill, which allowed senators to offer and vote on unlimited amendments to the legislation, called a vote-a-rama.  Once the Senate passed a bill, the next step would be a conference committee where representatives from the House and Senate could write compromise legislation that could pass both chambers.

On July 25, the motion to proceed passed with 50 “yea” votes and 50 “nay” votes on debating H.R. 1628.  Vice President Mike Pence performed his constitutional duties by casting the tie-breaking vote.  Every Democrat voted “nay” on proceeding to debate the House bill.  All Republicans voted “yea” except for Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska).

From there, the process faced many problems.  Several amendments to the House bill were offered, including Amdt. 270, a new version of BCRA, which failed by a vote 57 to 43.  The amendment included a proposal by Sen. Ted Cruz (R-Texas) that would have allowed a health insurer to sell plans that did not comply with Obamacare mandates as long as the company also offered a plan compliant with those current mandated benefits.

On July 26, the most telling vote was taken on Amdt. 271, the Obamacare Repeal Reconciliation Act, which failed by a vote of 45 to 55.  The amendment was practically identical to H.R. 3762, the repeal legislation that passed the Senate in 2015 by a vote of 52 to 47, in which every Republican senator voted “yea,” except Sen. Collins.  But now that it mattered, seven Republican senators reversed their position and voted “nay,” just as 18 House Republicans did in May.

On July 27, Leader McConnell attempted to pass a “skinny” repeal amendment, Amdt. 667, the Health Care Freedom Act.  The main purpose was to get a bill passed out of the Senate in order to keep the process going forward and allow a conference committee between the House and the Senate to write more comprehensive legislation.  The amendment kept most of Obamacare in place but repealed the individual mandate, suspended the employer mandate until 2025 and the medical device tax for three years, expanded state innovation wavers, and defunded Planned Parenthood for one year.  The amendment failed by a vote of 49-51 and was the last vote taken before the Senate left for August recess.

It is unclear what will happen when Congress returns to Washington.  Senate Health, Education, Labor, and Pensions Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) have called for bipartisan hearings to determine ways to provide short-term stabilization of the Obamacare marketplaces to lower premiums; in other words, provide cash payments to insurers.  The senators hope to have a bill written by the end of September.

Sens. Bill Cassidy (R-La.), Lindsey Graham (R-S.C.), and Dean Heller (R-Nev.) are working on legislation they hope to offer by the end of September.  Their legislation would repeal the individual and employer mandates, block grant Medicaid spending to the states, and turn over any federal funding being spent on Obamcare to the states to allow the states more flexibility in regulating health insurance and encouraging local innovation.

On July 31, Reps. Tom Reed (R-N.Y.) and Josh Gottheimer (D-N.J.), co-chairmen of the Bipartisan Problem Solvers Caucus, announced their solutions to move healthcare reform forward.  The 43-member group is calling for a stability fund to reduce insurance premiums, raising the threshold when employers must offer health insurance from 50 to 500 or more employees, eliminating the medical device excise tax, and bringing cost-sharing reduction payments under Congressional oversight with mandatory funding.

Meanwhile, the Convergence Health Roundtable, composed of conservative and liberal health policy wonks, have been working together to come up with policy recommendations.  Recognizing that the ACA is in fiscal trouble, their August 8, 2017 statement called for wider flexibility for states to manage their private health insurance markets and Medicaid, greater use of HSAs, and giving states options to encourage people to buy and keep health insurance, beyond an individual mandate.

Whether any of these policy ideas gain traction when Congress returns is hard to say.  Failure to repeal Obamacare in a timely manner is slowing up other critical issues including tax reform, the budget process, and appropriations.  Questions are being raised if Republicans can even govern.  But one thing is certain:  the Republicans have promised to repeal and replace Obamacare for seven years.  Failure to do so is not an option.

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